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      LUMBAR DISC HERNIATION

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          Abstract

          Lumbar disc herniation is the most common diagnosis among the degenerative abnormalities of the lumbar spine (affecting 2 to 3% of the population), and is the principal cause of spinal surgery among the adult population. The typical clinical picture includes initial lumbalgia, followed by progressive sciatica. The natural history of disc herniation is one of rapid resolution of the symptoms (four to six weeks). The initial treatment should be conservative, managed through medication and physiotherapy, sometimes associated with percutaneous nerve root block. Surgical treatment is indicated if pain control is unsuccessful, if there is a motor deficit greater than grade 3, if there is radicular pain associated with foraminal stenosis, or if cauda equina syndrome is present. The latter represents a medical emergency. A refined surgical technique, with removal of the extruded fragment and preservation of the ligamentum flavum, resolves the sciatic symptoms and reduces the risk of recurrence over the long term.

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          Most cited references 48

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          Full-endoscopic interlaminar and transforaminal lumbar discectomy versus conventional microsurgical technique: a prospective, randomized, controlled study.

          Prospective, randomized, controlled study of patients with lumbar disc herniations, operated either in a full-endoscopic or microsurgical technique. Comparison of results of lumbar discectomies in full-endoscopic interlaminar and transforaminal technique with the conventional microsurgical technique. Even with good results, conventional disc operations may result in subsequent damage due to trauma. Endoscopic techniques have become the standard in many areas because of the advantages they offer intraoperatively and after surgery. With the transforaminal and interlaminar techniques, 2 full-endoscopic procedures are available for lumbar disc operations. One hundred seventy-eight patients with full-endoscopic or microsurgical discectomy underwent follow-up for 2 years. In addition to general and specific parameters, the following measuring instruments were used: VAS, German version North American Spine Society Instrument, Oswestry Low-Back Pain Disability Questionnaire. After surgery 82% of the patients no longer had leg pain, and 14% had occasional pain. The clinical results were the same in both groups. The recurrence rate was 6.2% with no difference between the groups. The full-endoscopic techniques brought significant advantages in the following areas: back pain, rehabilitation, complications, and traumatization. The clinical results of the full-endoscopic technique are equal to those of the microsurgical technique. At the same time, there are advantages in the operation technique and reduced traumatization. With the surgical devices and the possibility of selecting an interlaminar or posterolateral to lateral transforaminal procedure, lumbar disc herniations outside and inside the spinal canal can be sufficiently removed using the full-endoscopic technique, when taking the appropriate criteria into account. Full-endoscopic surgery is a sufficient and safe supplementation and alternative to microsurgical procedures.
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            Surgical versus nonoperative treatment for lumbar disc herniation: four-year results for the Spine Patient Outcomes Research Trial (SPORT).

            Concurrent, prospective, randomized, and observational cohort study. To assess the 4-year outcomes of surgery versus nonoperative care. Although randomized trials have demonstrated small short-term differences in favor of surgery, long-term outcomes comparing surgical to nonoperative treatment remain controversial. Surgical candidates with imaging-confirmed lumbar intervertebral disc herniation meeting SPORT eligibility criteria enrolled into prospective, randomized (501 participants), and observational cohorts (743 participants) at 13 spine clinics in 11 US states. Interventions were standard open discectomy versus usual nonoperative care. Main outcome measures were changes from baseline in the SF-36 Bodily Pain (BP) and Physical Function (PF) scales and the modified Oswestry Disability Index (ODI - AAOS/Modems version) assessed at 6 weeks, 3 months, 6 months, and annually thereafter. Nonadherence to treatment assignment caused the intent-to-treat analyses to underestimate the treatment effects. In the 4-year combined as-treated analysis, those receiving surgery demonstrated significantly greater improvement in all the primary outcome measures (mean change surgery vs. nonoperative; treatment effect; 95% CI): BP (45.6 vs. 30.7; 15.0; 11.8 to 18.1), PF (44.6 vs. 29.7; 14.9;12.0 to 17.8) and ODI (-38.1 vs. -24.9; -13.2; -15.6 to -10.9). The percent working was similar between the surgery and nonoperative groups, 84.4% versus 78.4% respectively. In a combined as-treated analysis at 4 years, patients who underwent surgery for a lumbar disc herniation achieved greater improvement than nonoperatively treated patients in all primary and secondary outcomes except work status.
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              Nomenclature and classification of lumbar disc pathology. Recommendations of the Combined task Forces of the North American Spine Society, American Society of Spine Radiology, and American Society of Neuroradiology.

               P Milette,  D Fardon,   (2001)
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                Author and article information

                Contributors
                Journal
                Rev Bras Ortop
                Rev Bras Ortop
                Revista Brasileira de Ortopedia
                Elsevier
                2255-4971
                16 November 2015
                January 2010
                16 November 2015
                : 45
                : 1
                : 17-22
                Affiliations
                [1 ]Titular Professor of Orthopedics and Traumatology, Catholic Pontificate University of Paraná, and Spinal Surgery Group, Cajuru University Hospital, Curitiba
                [2 ]Spinal Surgery Group, Cajuru University Hospital, Catholic University of Paraná
                [3 ]Trainee in Spinal Surgery, Cajuru University, Catholic Pontificate University of Paraná
                Author notes
                [* ]Correspondence: Rua Brigadeiro Franco, 979 – 80430-210 – Curitiba, PRCorrespondence: Rua Brigadeiro Franco, 979CuritibaPR80430-210 vialle@ 123456uol.com.br
                Article
                S2255-4971(15)30211-1
                10.1016/S2255-4971(15)30211-1
                4799068
                27019834
                © 2010 Sociedade Brasileira de Ortopedia e Traumatologia

                This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

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